Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | 4301034721 | MI |
NPI | 1336352509 |
---|---|
Provider Name | Vivina Covacha Rosal |
First Address | West Bloomfield, MI 48323-3419 |
Second Address | West Bloomfield, MI 48323-3419 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/05/2007 |
Last Update Date | 21/10/2011 |